Michael Smith, MD (Host): Meaningful Medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future.

Today, I'm sitting down with Dr. David Hiller, and we're going to be talking about the rise of colorectal cancer cases in younger adults. But before we get started, Dr. Hiller, I always like to know from my guests, how did you go down the colorectal surgeon pathway? What was your passion? What motivated you?

Dr. David Hiller, MD: Yeah, I knew when I was in medical school that I wanted to be involved in cancer care and helping take care of patients who are dealing with cancer in some capacity. And once I knew that surgery was my calling and where my skills are going to be best used, then it was kind of figuring out what kind of surgeon involved in cancer do I want to be? You know, there's breast surgery, there's surgical oncology, there's all these different ways to go.

And in medical school, I had two fantastic mentors who were colorectal surgeons, and just to see the things that they could do in the operating room, the relationships they had in the office. I guess it's one of the few surgical fields where you still follow your patients long term. As opposed to just doing a procedure and then getting them to the next step. So, I really liked that component of still being able to take care of cancer through some complex surgeries in a field that was growing in terms of research and techniques, but to really help people and to have that relationship with them long-term. So, that's what dragged me into it, I would say.

Host: Fantastic. Love it. Listen, let's get right into this because it's concerning. Why are we seeing a rise and colorectal cancer cases among younger adults. What's going on?

Dr. David Hiller, MD: It's a great question. I don't think anyone has the best answer yet, probably something we're not going to be able to know for a long time until we can look back and see, you know, more retrospective data on why this is. But it is true. It's increasing. It's becoming, at this point, probably the second most common cancer in America if you combine men and women. And a lot of that increase is seen in a younger age than we've traditionally seen. Some people speculate, is this related to what we eat, our environment? Well, you know, what's going on? And there's a lot of theories there. I would say none that are definitely proven, but it is increasing. And while that is scary in the sense that we're seeing more of this at a younger age, I think the encouraging thing is that we have methods to detect it early and to get it before it grows or spreads. And so, getting people screened sooner and talking about it more like we're doing today is going to help, because we can do something about this. We can get this better.

Host: Yeah. You know, you wonder because the standard American diet has been pretty poor nutritionally speaking for decades. The environment's been pretty bad for decades. It just so makes you wonder, is there something else underlying this that we're missing? So, I'm glad to hear that you guys are looking into this, and I'm sure we'll figure it out someday. if you're listening to this and you're a younger person, can you share with them what would be some of the symptoms that they might want to just keep in the back of their head in case they start developing?

Dr. David Hiller, MD: The biggest symptom, the most common way that someone's going to present or notice something's wrong is seeing blood in stool when you go to the bathroom, maybe on toilet tissue. And traditionally, people say, "Oh, it must be a hemorrhoid." That's the common story. "Oh, I've had this hemorrhoid that's been bothering me for six to eight months." Hemorrhoids don't last for six to eight months. They last for three to six weeks, right? So, stories like that are the common ones. So bleeding, bleeding is abnormal. And to that, I would say, just get checked out. Let one of us say, which is a very quick check, to be like, "Yep, that's hemorrhoid. And here's what you can do," and then carry on. It's a very easy thing to rule out. But a lot of people just assume that's the case and that it'll go away. And then just, as life goes, we all push things off. It's easy to do, because a lot of people aren't experiencing pain if they're having early signs of colon cancer. They're not experiencing a lot of major changes. That happens way later in the disease process. Sometimes, not at all.

So, it's going to be subtle signs. Bleeding most commonly, maybe a change in how you go to the bathroom, maybe some bloating or some unexplained weight loss. But it's usually on the more subtle front outside of bleeding. That's the big red flag of, "Hey, just have someone take a quick look, make sure if nothing else is going on."

Host: Yeah. I'm glad you brought up the pain as something that is often early on, not part of the symptomatology of colorectal cancer, right? Because, you know, a lot of people out there, if you ask them, you know, "How's your gut and how do you feel?" And they're like, "Oh, everything feels fine," and they touch themselves as if they're going to feel pain, right? So, it's good that you mentioned that that's actually a later thing that somebody might experience. Now, when it comes to recommending screening age, didn't this change already a few years ago?

Dr. David Hiller, MD: Yes. The major task force for cancer in America several years ago recommend knocking it down to 45 from 50 for everyone, 45 across the board, which I think is a great recommendation. I would not be surprised in the future if that gets pushed down to 40. But for right now, 45, I think that's the way to go outside of having symptoms or significant family history or something else medically that would make you go sooner than 45, but 45 is now the age to start.

Host: So, family history, you might start at 40 or something. You might have a more aggressive approach to this, right?

Dr. David Hiller, MD: Right. If you have a significant family history that can bump the age down, it can be 40, sometimes sooner. If you had a mother, father, or a sibling who had colorectal cancer before the age of 60, sometimes we say 10 years before their diagnosis. So if they were diagnosed at 42, then we would tell you 32. So, there's some other instances. And that's why it's good to know your family history as best you can. And to be able to present that to your doctors as part of an individualized plan, because this isn't one-size-fits-all, and that's why it's important to have that conversation. Know as much about your family as you can and talk to your family about what's going on, so everyone knows what's happening in their lives. So, you can share that and we can screen you correctly.

Host: Since we're talking about the rise of colorectal cancer in younger adults, and we're talking about family history a little bit here, when to get screened, have you noticed that, or some of these younger adults, do they have a strong family history colorectal cancer, or is that just part of the theory? We don't really know yet what's going on.

Dr. David Hiller, MD: It can seem that way, because the number of cases is increasing so much. You're going to see people within a family both have it. But we would say now maybe 5-10% of colon cancers are inherited, so a majority or not, or if they are and it's some inheritance that we aren't aware of, some gene or some defect genetically that we don't know we haven't diagnosed or worked that one out that we'll be working on finding. But conventionally, we would say right now 5-10% are inherited. This is something that's coming because of your genetics. The other, you know, 90% of these are just from life, the environment, biology, not necessarily your family or in a way that we can say for certain.

Host: Well, I think that's an important take-home message right there. So if you're listening to this, regardless of your family history, 45 is that new age, right? That's when we're going to start screening. Stick to that no matter what. I mean, that's a good message, I think, right?

Dr. David Hiller, MD: Absolutely. Because one of the pros, I would say, of colon cancer screening specifically with colonoscopy is this is probably the only screening tool that can also treat while you're screening, you know, a chestx-ray,For lung cancer is just going to see something's wrong. And then you go through a process after that. A mammogram is going to see that there's something concerning and then you need a biopsy, ultrasound, other things. The colonoscopy says, "Here's a problem and we're going to get rid of it right now and diagnose it, you know, take it, send it to the lab." So, it really is like a one-stop shop in terms of detection and treatment.

Host: interesting you bring that up because there are other tests out there that are available. What's your feeling about some of those, you know, whether it's a camera in a pill or a stool test, where does those fall? And it sounds like with you, colonoscopy is still that standard.

Dr. David Hiller, MD: Colonoscopy is the standard. To me, and I think most people in our profession would agree, if you can get a colonoscopy, that's the one to do. That's the best because it's going to find the problem. If there is one, it's going to take care of it right there. You remove the polyp before it becomes a cancer. That's the whole thing. If these colon cancers arise from polyps, it takes usually quite some time, years for these polyps to transform. So if you can get it with just a polyp, you take it out, that's it. Well, we watch you obviously with more scopes and other studies in the future, but that thing is gone. It's never going to turn into a cancer for you. So, the key is to get these polyps out before they can convert into something else.

So, other ways to detect it besides looking at it directly with a colonoscopy are, as you said, stool studies. There've been different stool studies around for a long time. People may have heard of things called like a FIT test or a fecal occult blood test. These cards that used to be given out in clinics, things you can mail in, give to your primary care provider, your gastroenterologist, And those are trying to pick up blood in the stool that wasn't visible to the eye to then say, "Hey, something's going on. Go get a colonoscopy." So, a lot of those stool tests still led you to the colonoscopy, but you could make an argument if you did the stool tests in the right intervals, usually it was yearly in the absence of other symptoms, could that replace to a certain extent colonoscopy.

Now, we have other tests that look for things within the stool, not just blood, but like DNA markers and Cologuard is the big one. They have advertisements all the time. And I would say that these are great tools for us to be developing and learning more about when it's appropriate to use them, but they are not a replacement for a colonoscopy. If a Cologuard is positive, you need to go get a colonoscopy. Cologuards can be negative, when really there is something in there, and that's an important thing for people to know, the amount of times a Cologuard can be wrong. It can tell you that there's something there when there isn't. And then, the opposite, it can tell you there's nothing there, and there is a problem. And I see that. I see patients who come in, say, "Well, I've had three negative Cologuards, they kept having issues." And we do a colonoscopy, and there's a cancer, or some big polyp. So, those tests aren't perfect, and that's why it still goes back to colonoscopy being the best.

Host: Now, one of the things that a lot of patients, let's say, fear the most about a colonoscopy is the prep process, getting ready for it, right? You know, you hear horror stories all over the place. It's gotten a little bit better, right? Can you help us confirm that? It's not as bad as people think.

Dr. David Hiller, MD: I mean, I would say so. I've had one myself. I didn't think my prep was anything atrocious compared to things that I know that we've done as a profession in the past. So, I mean, from personal experience, I didn't think it was that bad. It's not fair to put how well I dealt with it on everyone else. Everyone handles these things differently, right? But it is no longer the giant liters and liters jugs of stuff that it was back in the past. You know, things that I read about when I was learning, you know, in medicine of things we used to do, right? Rarely, those come up. I mean, that's still a tool, but that's not something your gastroenterologist or colorectal surgeon's got to really be putting in front of you, most likely.

A lot of times it's going to be things like Miralax, you know, over the counter stuff mixed in a liquid like a Gatorade or some kind of juice or water. There are things like Sutab is this tablet based one you have to drink a lot of water with and take these pills. There are these other ones that are solutions that you mix. So, there's no way of really getting around drinking some decent amount of fluid, but it's not liters, you know, gallons like it was before. And so, that makes it a lot more doable. And then, the way that we schedule them, the timing, knowing how long you can drink up before it, and kind of the way that we time when you drink these things to go, I think has made it a lot more doable. So, it is definitely what's on everyone's mind. It's what we get the most questions about. A lot of people find out afterwards, I think a common thing I hear in the office is someone who's been resistant to this for a long time and then they finally get it and they're like, "Oh, that was it? That was no big deal." And I'm like, "Yeah, it's really not." Not to downplay that there aren't safety concerns. There's always risks and issues with any procedure. I don't want to just play that off, that it's not important. It is. But it's a very safe procedure. The prep is very doable. Thousands of people in the country are getting it done every day, and getting it done safely and tolerating the prep. So, I think it's built up in a lot of people's minds. And if you go into it thinking, this is going to be awful, it's going to be awful. And if you go in being like, let's just get this over with, it probably won't be as bad.

Host: Yeah, no, don't go into it that way. I know a lot of people when they're done with the prep, they actually feel a little bit better. They feel a little bit not as bloated.

Dr. David Hiller, MD: People are paying a lot of money for these bowel cleanses you see online and stuff. You know, drink a whole bunch of like cayenne pepper and lemon, you know, not healthy ways of doing the same thing, I would say, in my experience. But yeah, that's what they're going for. And it's an interesting feeling when there's absolutely nothing in you, essentially.

Host: So, I read that six of Novant Health's hospitals are nationally accredited for rectal cancer. And I think that's out of like 96 total. That sounds fantastic, but what does that mean to the average patient?

Dr. David Hiller, MD: Yeah, It's fantastic news for our system and it's awesome that our cancer center has supported colorectal surgeons throughout Novant in making this happen. And so, what that means is, people listening to this might be familiar if you've been to a place that treats breast cancer and you'll see these signs that say, National Accreditation Breast Cancer Center of Excellence, COC, Commission on Cancer. Those are these big organizations that oversee cancer care in America, and they set standards, and they make sure that hospitals and physicians and teams live up to a certain standard, so that if you go to those places, you know they're being audited, they're being watched. This is the best of the best in that breast cancer care, for example. That's the most common one I think people see with this.

Some time ago, a lot of very smart colorectal surgeons said we need to up the game with rectal cancer. Rectal cancer and colon cancer are the same cancer in how they originate from a polyp. The rectum is the last 15 centimeters of the colon, the last part before it gets to the anus. The biology there is a little bit different because the anatomy is different. That part of rectum is surrounded by lymph node tissue and your bony pelvis. So, cancers there can grow differently and we have to treat them differently than a colon cancer. And historically, we would see higher rates of cancer growing back for people who had rectal cancer care. We saw differences in how surgery was done, differences in how chemotherapy was given, a lot of variation across the country. So, some really wise people said we need to copy the breast template, and we need to say, "What are the best ways to treat breast cancer? How can we reproduce that and have centers show that they do that all the time and prove that to themselves and to anyone else who needs to look at the numbers?" And then, we can say, "Yeah, these people are doing the best possible rectal cancer care." And we really wanted to pursue that here. We felt that we were giving that to our patients. And so, we wanted to, one, let everyone know that we were providing that level of care, but also to have mechanisms to keep us at that level. So, we went through this multi-year process of getting that approval, making sure we had systems in place. It's coordination between surgeons like myself, and my partners, the medical-oncologists, the radiation-oncologists, pathologists, radiologists, geneticists, cancer navigators, tons of people involved in this. And we streamlined our processes. We made sure that our teamwork was just really locked in, that we were making sure everyone was getting the best possible care they could. And then. We had someone from this National Accreditation Center come in and look at our records over a one-year period. And they told us, we met every mark. We had no deficiencies. We got immediate approval. And every Novant hospital's gotten that. We haven't had any deficiencies in any category, which is amazing.

Most places have some. And that's the testament to the hard work of the teams in Winston and in Charlotte. So, it's hospitals in Winston and Charlotte that have gotten this and our teams have worked together, which has just been great to have that collaboration. But what it tells patients is that you're getting the best possible care for rectal cancer and you're getting team-based care. It's not you come to me with your rectal cancer and I'm going to have all the answers. It's myself, my partners, the medical-oncologists, radiation-oncologists, all of us working together. So when you go to the next appointment, no one's saying, "Well, what did the last guy do? What did the last person say? Or what do they think?" We all know, we've all talked together. We've worked on this as a team. And so, we're able to present a unified front so things don't get missed. People are getting the best possible care. All options are laid out. And then, we make sure we stay on top of the standards.

Host: Fantastic. Dr. Hiller, this was great information. Very important information. I'm going to thank you for coming on the show with me today. To find a physician, you can visit novanthealth.org. For more

health and wellness information from our experts, visit healthheadlines.org.

Michael Smith, MD (Host): For supportive care throughout your cancer journey, visit nh. team. com. I'm Dr. Mike. Thanks for listening.